Church Walk Surgery

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

The service worked well across teams and services to support people. Assessment of patients care needs were not always consistently completed and evidence based guidelines were not always followed. Staff made sure people understood their care and treatment to enable them to give informed consent.

This is the first assessment of the service and we rated this key question as good.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Our remote searches identified inconsistent assessment of needs for patients with some long term conditions and patients taking medicine that require monitoring. The provider has told us they have changed the processes that were in place to improve the management of these patients.

The service had recently introduced the use of templates for clinical staff when conducting care reviews to promote consistency and to support the review of people’s wider health and wellbeing.

The changes had not been in place long enough to assess their full impact and evidence ongoing sustainability.

Reception staff were aware of the needs of the local community. Staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked peoples’ health, care, and wellbeing needs during health reviews.

The provider had systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service did not always make sure patients’ care and treatment were effective. Patients did not always receive the required reviews for their care and treatment within the required timeframes.

The remote clinical searches that we undertook of the practices’ clinical records system showed the monitoring of people with long-term conditions varied. It was not always in line with national guidance, evidence and recommendations. For example:

We found 21 patients living with asthma who have been prescribed 2 or more courses of rescue steroids to manage acute exacerbation of the condition. We reviewed 4 randomly selected records all of which had aspects of management that had not followed evidence based guidance. For example, inadequate clinical assessment recorded, no steroid card issued, no evidence of a spacer being offered or documentation to say it was not required, follow up not arranged in line with national guidance and overdue annual asthma reviews. The provider took immediate action to review the 21 patients and review care received. A plan is now in place to carry out monthly audits to prevent recurrence and an Asthma 48-Hour Review Policy has been introduced.

Clinical searches identified 15 patients with a potential missed diagnosis of diabetes. Review of 3 patients identified concerns related to results which appeared to have been filed incorrectly and therefore patients had not been managed or followed up appropriately. The practice could not be assured that the remaining 12 results had been filed correctly. Following our assessment the practice reviewed the remaining records and contacted the patients identified and arranged an urgent review if required. We were told a plan was put in place to run monthly searches to prevent reoccurrence.

Out of 214 patients with hypothyroidism our searches identified the vast majority had been appropriately monitored in line with national guidance. The patients overdue a blood test were contacted and appointments made to attend the practice.

We reviewed patients with Chronic Kidney Disease Stages 4 or 5 and patients living with diabetes who had all been managed appropriately in line guidance.

The provider was responsive to the issues we identified and acted to manage and mitigate any immediate risks. Following our assessment we received confirmation of changes to the systems and processes in place to improve the delivery of evidence-based care and treatment. These included the changes to the processes in place to manage long term condition monitoring and reviews, review of test results for missed diagnosis, management of all test results and an updated asthma policy to include national guidance.

The changes had not been assessed or reviewed to evidence impact and ongoing sustainability.

The service worked well across teams and services to support people. Staff had access to the medical records but they did not always contain the information needed to assess, plan and deliver peoples’ care, treatment and support. For example, the information for some long term conditions and medicines that require monitoring was not always correct.

Feedback received from care homes using the service was positive and they told us they had seen many improvements since the new provider took over the service.

Staff feedback was positive about how they worked together with the service. For example, there was team working across different staff groups to address issues such as follow up of people who failed to attend important appointments. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. For example, the wider multidisciplinary team to support vulnerable people and the ‘care home team’.

When people receive care from a range of different staff, teams or services, it is co-ordinated effectively. All relevant staff, teams and services are involved in assessing, planning and delivering people's care and treatment and staff work collaboratively to understand and meet people's needs.

People had access to services provided by the Primary Care Network (PCN), including, social prescribers and extended access appointments. Mutual support and learning were shared across the PCN. The service had worked with their PPG to make improvements to the service.

National data showed that all 5 indicators for childhood immunisations had achieved the minimum 90% uptake target, with 3 of the 5 having achieved the 95% World Health Organisation based target for uptake and had been consistent over time.

National data showed the uptake of cervical screening had been consistent over time and close to or above the national target of 80%.

The number of patients attending screening for bowel and breast cancer for the period of 2023 to 2024 (latest figure available) is in line with national figures.

People are encouraged and supported to make healthier choices to help promote and maintain their health and wellbeing. A variety of health promotion information was available in the practice, on social media and the practice website. We saw evidence that the clinical system included identifying alerts for patients who may specifically benefit from a variety of health promotion initiatives. Staff told us options for advice and support would be discussed with patients at every opportunity.

Peoples’ care and treatment was not always routinely monitored in line with national guidance and appropriate actions taken to improve it. The systems in place to ensure that people with long term conditions were reviewed regularly, taking medication that required monitoring, medicine reviews, MHRA safety alerts actioned and test result reviews were not always effective.

Following our assessment we received confirmation of changes to the systems and processes in place to improve the monitoring of care delivery. These included the introduction of a standardised approach to medication reviews and monitoring, changes to the system to manage long term condition monitoring and reviews, review of test results.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation.